OUTCOMES OF SURGICAL MANAGEMENT OF …...elevated the leg on Bohler-Braun splint with non-adhesive tracon. In case of delayed surgery, lower bial skeletal tracon with proper weight

Sah S et al

OUTCOMES OF SURGICAL MANAGEMENT OF DISTAL FEMUR FRACTURE WITH DISTAL FEMORAL LOCKING

COMPRESSION PLATE AT KOSHI ZONAL HOSPITAL

Affiliation

1. Department of Orthopedics, Koshi Zonal Hospital, Biratnagar,

Nepal

2. Associate Professor, Department of Orthopedics, Nobel Medical

College & Teaching Hospital, Biratnagar

3. Department of Anesthesiology, Koshi Zonal Hospital, Biratnagar,

Nepal

4. Department of Physiotherapy, Koshi Zonal Hospital, Biratnagar,

Nepal

A R T I C L E I N F O

Article History

© Authors retain copyright and grant the journal right of first

publication with the work simultaneously licensed under

Creative Commons Attribution License CC - BY 4.0 that allows

others to share the work with an acknowledgment of the

work's authorship and initial publication in this journal.

Received : 19 September, 2017

Accepted : 11 October, 2017

Published : 31 December, 2017

Citation

Sah S, Karn NK, KC B, Yadav R, Dangi SJ, Adhikari AR. Outcomes

of Surgical Management of Distal Femur Fracture with Distal Femoral Locking Compression Plate At Koshi Zonal Hospital. BJHS 2017;2(3)4 :260-265

* Corresponding AuthorDr. Shambhu Sah

Department of Orthopedics

Koshi Zonal Hospital

Biratnagar, Nepal.

Email: [email protected]

ORA 40

Original Research Article

1* 2 1 1 3 4Sah S, Karn NK, KC B, Yadav R, Dangi SJ, Adhikari AR

ABSTRACT

Introduc�on

Distal femoral fractures comprise 4-6% of all femur fractures. The management of distal femur fractures are challenging because of significant morbidity and complica�on rate even with advanced surgical techniques and implants. Open reduc�on and internal fixa�on (ORIF) with pre-contoured distal femoral locking compression plate (DF-LCP) is one of the most acceptable surgical procedures these days.

Objec�ve

Evalua�on of func�onal outcomes of distal femur fractures managed surgically using DF-LCP at Koshi Zonal Hospital.

Methodology

In this cross sec�onal study 21 pa�ents having closed distal femur fractures with or without intra-ar�cular extension to femoral condyle fixed with DF-LCP at Koshi Zonal Hospital, Nepal from March 2016 to March 2017 were included. Pa�ents with open fracture, severe comminuted fracture, and neurovascular impairment were excluded. These pa�ents were followed-up for up to one year and we recorded the knee range of mo�on, full weight bearing �me fracture union �me, and complica�ons. We used Neers' func�onal scoring system to evaluate the final outcomes and data was analysed using Microso� Excel Programe.

Results

Out of the 21 pa�ents of distal femur fractures, 16 were dia-metaphyseal distal femur fractures and five were supracondylar fractures with intra-ar�cular extension. Mean age recorded was 45 (range 19-75) years, hospital stay mean dura�on 12 (range 10-19) days and dura�on of surgery 85 (range 60-150) minutes, full weight bearing walking �me mean16 (range 12-22) weeks, radiological union �me mean 20 (range 17-29) weeks and Neers' score was excellent in 66.66%, sa�sfactory in 23.80%, unsa�sfactory in 4.76%, and poor in 4.76%.None of our pa�ents had complica�ons like; loss of fixa�on, implant failure or post-opera�ve neurovascular injury.

Conclusion

Distal Femoral Locking Plate is one of the best implant to be used as fixa�on method for both extra-ar�cular and intra- ar�cular distal femur fracture.

KEYWORDS

Distal femur fracture; open reduc�on ; plate fixa�on

260Birat Journal of Health Sciences

ISSN: 2542-2758 (Print) 2542-2804 (Online) Vol.2/No.3/Issue 4/ Sept-Dec 2017

DOI: h�p://dx.doi.org/10.3126/bjhs.v2i3.18939

http://dx.doi.org/10.3126/bjhs.v2i3.18939

Original Research Article Sah S et al

INTRODUCTION

Distal femur fractures are uncommon but challenging injuries to treat. In older age males and females with osteoporo�c bone, fractures are usually due to low energy trauma like fall from standing height or during walk. However in young pa�ents, these fractures occurs due to high energy trauma

1,2like motor vehicle accidents, sports injuries and fall from height.

Conserva�ve management such as trac�on, cas�ng or combina�on of both demands prolonged bed rest and can result in persistent angular deformity, bed sores and loss of knee range of mo�on.Surgical fixa�ons has consistently demonstrated be�er outcomes than nonsurgical management. At present, early return to func�on is possible due to the development of new technology and newer implants for distal femoral fractures. Commonly used implants are external fixators, angled blade plates, dynamic condylar screw plates, condylar bu�ress plates, retrograde supra-condylar inter-locking nails, Ender's nails, Rush nails etc. These implants are selected based on the fracture pa�ern, bone quality, func�onal demands and type of trauma, the condi�on of the pa�ent and exper�se of the surgeon. Most of these implants require C-arm fluoroscopy during opera�ve period of fixa�on. Newly introduced distal femoral locking compression plate (DF-LCP) is pre-contoured, which provides angular stability and rigid

3-5 fixa�on. Objec�ve of our study is to analyses the func�onal outcomes of ORIF with DF-LCP in distal femur fractures.

METHODOLOGYThis cross sec�onal study was conducted on 21 pa�ents admi�ed in orthopedic department of Koshi Zonal Hospital, Biratnagar, Nepal from March 2016 to March 2017 to analyze of the outcomes of surgical management in distal femur fractures with DF-LCP. In this study, we selected adults (skeletally mature) above 18 years and elderly with osteoporo�c bone. Simple spiral, oblique, transverse and bu�erfly fragment with simple intra-ar�cular extension were included but comminuted dia-metaphyseal fractures, open fractures and fractures with neurovascular injuries were excluded. We took convenient sample for this study. Ethical clearance was taken from hospital authority. No pa�ent was harmed physically and economically for this study except their regular expenditure for treatment. Data was analyzed using Microso� Excel Program.

PRE-OPERATIVE MANAGEMENT

In the emergency department of Koshi Zonal Hospital, we examined thoroughly not only distal femur fracture but also carefully considered the mechanism of injury,mode of injury, associated injuries such as neurovascular injury, head injury and other system involvement. We started emergency treatment and required inves�ga�ons such as X-Ray, CT scan especially in head injury or intra-ar�cular femoral condyle fractures and other rou�ne blood inves�ga�ons. Once the pa�ent became stable, we shi�ed the pa�ent to the ward, elevated the leg on Bohler-Braun splint with non-adhesive trac�on. In case of delayed surgery, lower �bial skeletal trac�on with proper weight was applied. We prepared the pa�ent for surgical management a�er pre-anesthe�c checkup (PAC). Informed consents were taken for all the surgeries.

SURGICAL TECHNIQUE

A�er pre-anesthe�c checkup, all pa�ents received regional spinal anesthesia. The pa�ent was placed supine on a radiolucent opera�ng table. Sand bag was placed under the ipsilateral hip, another rolled towel was placed under the knee to achieve flexed posi�on of the knee, length and rota�on was carefully controlled. We applied tourniquet in some pa�ent depending on length of femur and extension of fracture. Routine preparation and draping of injured limb was done. Lateral incision (sub-vastus approach) was made directly on the lateral aspect of the thigh and through the midpoint of the lateral condyle distally, staying anterior to the proximal inser�on of the lateral collateral ligament. The distal end of the incision was gently curved anteriorly along the lateral border of the patella upto the �bial tuberosity. Proximally incision extended as per requirement. The fascia lata was incised in line with skin incision and its fibers were split. Distally for condylar fracture exposure, it was o�en necessary to incise the anterior fibers of the ilio�bial tract and carry down through the capsule and synovium of lateral aspect of the femoral condyle. Care was taken to iden�fy the superior lateral genicular artery, which was ligated and

6-8to avoid damage to the lateral meniscus. Adequate exposure of ar�cular surface, par�cularly, medial femoral condyle or coronal plane anatomy was managed by extension of incision as per necessity.

Figure 1: Distal Femur diametaphyseal fracture ( non-ar�cular involvement)

(A) Pre-op x-ray non intra-ar�cular involvement (B) Post-op x-ray non intra-ar�cular involvement

ISSN: 2542-2758 (Print) 2542-2804 (Online)

Birat Journal of Health Sciences Vol.2/No.3/Issue 4/ Sep-Dec 2017

261


Vastus-lateralis muscle was reflected of lateral inter-muscular septum to expose the distal femoral sha�. Fracture reduc�on was achieved commonly by manual trac�on. For reduc�on of condylar fractures, we temporarily used mul�ple K-wires. Pre-contoured DF-LCP was placed and fixed with 3-

Figure 2: Distal Femur Intra-ar�cular Extension

5 cancellous locking screws distally and 3-5 cor�cal locking screws proximally. Hemostasis maintained and wound closure was done in layers a�er placement of suc�on drain. A�er dressing above knee POP slab was applied with knee

9at 15-20 degree flexion in intra-condylar fracture.

(A) Pre-op x-ray intra-ar�cular involvement (B) Post-op intra-articular involvement

Suc�on drain was removed a�er 48-72 hours depending upon drain collec�on. Intravenous an�bio�c was used for 5-7 days according to pa�ent's health condi�on, hygiene, nutri�onal status, socioeconomic status, pa�ent's habit of alcohol intake and smoking. Repeat hemoglobin was done for post-opera�ve blood transfusion cases. Sutures removed according to wound healing condi�on at around

th13 day. Plaster of Paris (POP) long leg back slab was applied in every cases and removal was done depending on condi�on of wound healing, post-opera�ve x-ray bone fixa�on, bone density,

pa�ent's behavior, and pa�ent's hygiene maintenance. Isometric quadriceps and hamstring strengthening exercises

ndwere started a�er 2 postopera�ve day and ac�ve mobiliza�on was ini�ated a�er two weeks by physiotherapist. In most of the cases, we removed POP back slab a�er two weeks, but in older pa�ents, osteoporo�c or intra-ar�cular fracture slab was removed a�er around 3-5 weeks. Par�al and full weight bearing walking was allowed on clinical and radiological evidence on follow up at 6 weeks interval. During follow up, outcomes were assessed by using Neers' func�onal scoring system up to six months.

10,11Table 1 : Neers' Func�onal scoring.

Pain (20 units)5. No pain .................................. 204. Intermi�ent .................................. 163. With fa�gue .................................. 122. Restrict func�on ............................... 81-0. constant or at night .......................... 4-0Func�on (20 units) 5. As before injury ................................ 204. Mild restric�on .................................. 163. Restricted, stairs sideways ................ 122. Cane or severe restric�on.................. 81-0. Crutches or brace ............................. 4 -0Mo�on (20 units) Knee Flexion5. Normal or 135 degrees .................... 204. 100 degrees ................................ 163. 80 degrees ................................ 122. 60 degrees ................................ 81. 40 degrees ................................ 40.20 degrees or less ................................ 0Work (10 units)5. As before injury ................................ 104. Regular but with handicap ............... 83. Alter work ................................ 62. Light work ................................ 41-0. No work ................................ 2-0

Gross Anatomy (15 units)5. Thickening only .......................................... 154. 5 degrees angula�on or 0.5 cm short .......................................... 123. 10 degrees angula�on or rota�on, 2.0 cm short-0 .......................................... 92. 15 degrees angula�on or rota�on, 3.0 cm short .......................................... 61. union but with greater deformity ............................ 30. non union or chronic infec�on................................... 0Roentgenogram (15 units)5. Near Normal .......................................... 154. 5 degrees angula�on or 0.5 cm displacement- .......................................... 123. 10 degrees angula�on or 1.0 cm displacement .......................................... 92. 15 degrees angula�on or 2.0 cms displacement .......................................... 61. Union but with greater deformity; spreading of condyles; osteo-arthri�s...................... 30. Nonunion or chronic infec�on.................................. 0

Func�onal ..........................................(70 Units) Anatomical ............................................................... (30 Units)

Overall Ra�ng: Excellent Above 85 units, Sa�sfactory 70-85 units, Unsa�sfactory 55-69 units, Failure Below 55 units

POSTOPERATIVE PROTOCOL




RESULTS

Twenty-one pa�ents were included in this study with average age 45 (range 19-75) years. Among them 14 were female (range 27-75) years and seven were male (range 19-35) years. Five cases had intra-ar�cular involvement and 16 cases were with dia-metaphyseal fracture mostly oblique and spiral. The �me between injury and surgery was mean 9 (range 5-13) days. Eleven pa�ents required blood transfusion before opera�ve procedure and three pa�ents got blood transfusion a�er surgery. All the cases were operated under spinal anesthesia. Dura�on of surgery was average 85 (range 60-150) minutes and average blood loss was 208 (range 150-300) ml without intraopera�ve complica�ons. Opera�ve dura�on and blood loss was more in intra-condylar fractures, bulky pa�ents and fractures with difficult reduc�on. All pa�ents started isometric hamstring, gluteal and quadriceps exercises as taught by the

ndphysiotherapist on the 2 post-opera�ve day and was con�nued �ll full range of movement of knee was achieved. Pa�ents were on intravenous an�bio�cs a�er surgery for (5-7) days depending upon wound condi�ons which was switched to oral an�bio�cs �ll suture removal (range 12-14) days. Dura�on of hospital stay was average 12 (range 10-19) days. All pa�ents were ambulated with non-weight bearing using crutches or walker a�er removal of sutures, except those five pa�ents with inter-condylar fracture. Full weight bearing was allowed when the fracture union was confirmed both clinically and radiologically on average 16 (range 12-22) weeks. Inter-condylar fractures, osteoporo�c bone and pain sensi�ve pa�ents took longer �me for full weight bearing.

Radiological union of the fracture was characterized by cortex to cortex healing and bridging callus of the fracture in both antero-posterior and lateral views of follow-up x-rays, average union �me was 20 weeks (range 17-29). Neers' scorings recorded at six months post-op with the help of physiotherapists. Score assessment was excellent in 66.66%, sa�sfactory in 23.80%, unsa�sfactory in 4.76% and poor in 4.76%. Five pa�ents complained of knee pain a�er radiological healing. Early complica�ons were encountered in three pa�ents, out of which two pa�ents had developed superficial wound infec�on and one pa�ent had deep infec�on. They were managed with intravenous an�bio�c and proper dressing. None had any implant failure or any deformity.

DISCUSSION

The introduc�on of distal femoral locking compression plate (DF-LCP) with fixed-angle screws system offers a number of advantages in fracture fixa�on and DF-LCP has been rapidly adopted as an alterna�ve to intramedullary nails, blade

plates and non-locking condylar screws. Distal femur fracture reconstruc�on needs a very skillful hand because it's a very challenging procedures for the orthopedic surgeons. The goal of the reconstruc�on is not only the anatomical reduc�on of the ar�cular surface but also the adequate stabiliza�on of the fracture and early mobiliza�on

along with preven�on of the s�ffness and early ambula�on of the pa�ent.The prognos�c factors described for distal femur fracture are age, fracture types, ar�cular involvement, proper implant selec�on, �ming of joint mo�on and

12-15surgeon's exper�se. The outcomes of DF-LCP in distal femur correlated with the fracture severity, e�ology, anatomic reduc�on, bone quality, length of �me elapsed from injury to surgery, concomitant injuries and proper posi�oning and fixa�on of the implant. Any slight varia�on in implant placement can disturb reduc�on. DF-LCP is very much user-friendly technique because it makes anatomical reduc�on and fixa�on easier. It is ideal implant when

rd the fracture of lower 1/3 femur has an intercondylar 16-18extension.

Table 2: Comparison of hospital stay , opera�ve �me, weight bearing walking, radiological union ORIF with DF-LCP with other published ar�cles

Surgical fixa�on of distal femur fractures has consistently demonstrated be�er outcomes than nonsurgical management based on fixed angle devices star�ng with ORIF using condylar blade plate (CBP) or Dynamic Condylar Screw (DCS). However, it requires large incisions that led to increasing complica�on rates of infec�on, delayed union, non-union, itera�ve fractures

and need for primary or secondary bone gra�ing. For minimizing those disadvantages, close reduc�on and minimal exposure to facilitate the inser�on of retrograde intra-medullary nail with preserva�on of periosteum and fracture hematoma. Newly introduced minimal invasive plate osteosynthesis (MIPO) techniques were successfully applied in complex extra-ar�cular fractures and a modified technique en�tled Transar�cular Approach and Retrograde Plate Osteosynthesis (TARPO) was developed for complex

19-21supracondylar and intercondylar femoral fractures.

Table 3: Comparison of Neers' scores of ORIF with DF-LCP



263


Since the use of pla�ng and nailing technique has modernized, there has been a major improvement in the treatment of distal femur fractures. The revision surgery is co-related with the surgical skills of the surgeon, implant and the type of fracture. Selec�on of the appropriate implant depends upon the fracture pa�ern, the condi�on of the so� �ssues, the need of the pa�ent, and the preference of the surgeon.

The mean age of pa�ents were higher, which could explain the higher mortality rate. The outcome and the prognosis of fracture depends on micro-mo�on and stable fixa�on. There are certain variables that can be controlled by surgeons and some are uncontrollable. Among the uncontrollable variables, the poor bone quality of the pa�ent and the

22-23fracture comminu�on also plays a vital role.

Table 4: Comparison with commonly used different implants and techniques in terms of duration of

hospital stay, radiological union, blood loss, operative time and Neers' score

Technically retrograde nailing is said to be a challenging procedure due to its certain complica�ons like; iatrogenic fracture of femoral sha�, stress fracture above the implant, fa�gue failure of the nail, intra-ar�cular impingment of the nail due to inadequate entry point, knee pain and injury to the deep femoral artery. In supracondylar fracture femur, supracondylar nailing is useful for fixa�on but not in case of comminuted fractures. In comparison with supracondylar nail, DCS is supposed to be a be�er op�on for management of distal end of femur fracture in terms achieving bony union with less chances of knee s�ffness, knee arthrosis and be�er Neers' score. In supracondylar nailing group there is benefit of early weight bearing. Drawback of using plate and screws is that plate is a load shielding device and is prone re-

24-25fractures in osteopenic bone of the proximity of the plate.

However, MIPO does not allow direct visualiza�on of the fracture and the surgeon is dependent on intraopera�ve fluoroscopy for adequate reduc�on. The requirement for biological osteosynthesis led to the development of new genera�on of plates with angular stability, called Less Invasive Stabiliza�on System (LISS). The less invasive stabiliza�on system (LISS) is based on MIPO technique. The LCP differs from the LISS in that the LCP has combina�on holes and does not have a jig. The LCP acts on the principle of internal fixator and permits percutaneous pla�ng, as locking the screws to the plate do not pull the fracture towards the implant so that the fracture does not redisplace

a�er reduc�on. The LCP is compa�ble with MIPO.DF-LCP is a useful arsenal for orthopedic surgeons while fixing fractures around the knee especially when the fractures are

26-28severely comminuted and osteoporo�c.



CONCLUSION

The outcome of distal femoral fractures fixed with DF-LCP as shown by Neers' score is excellent with minimal complica�ons. Hence, the DF-LCP can be used as a safe and reliable implant for both intra and extra-ar�cular distal femur fractures to restore the length, rota�on and axial alignment of the femur.

RECOMMENDATIONS

With our study results, we recommend DF-LCP can be standard method of management of distal femur fracture.

LIMITATION OF THE STUDY

Our study was single center study and had small sample


size. Hence, we recommend a larger sample size and mul�-centric study with longer follow up.

ACKNOWLEDGMENT

Grateful to Dr. Roshan Pokhrel (Medical Superintendent), Dr. Mukund Dahal (HOD, Ortho-Department) and Mrs. Anjula Karki (OT-Incharge) from Koshi Zonal Hospital for suppor�ng in this study.

CONFLICT OF INTEREST

The authors declare no financial support or conflict of interest.

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Documents

OUTCOMES OF SURGICAL MANAGEMENT OF …...elevated the leg on Bohler-Braun splint with non-adhesive tracon. In case of delayed surgery, lower bial skeletal tracon with proper weight